SNAPSHOT OF APT QUALITY DATA 2015 - 2017 · SNAPSHOT OF APT QUALITY DATA 2015 - 2017 What’s happening in Arizona and in our APT facilities? Dean V Coonrod, MD-MPH Chair of the APRS/APT

SNAPSHOT OF APT QUALITY DATA 2015 - 2017

What’s happening in Arizona and in our APT facilities?

Dean V Coonrod, MD-MPH

Chair of the APRS/APT QI Committee

August 10, 2018

ACKNOWLEDGEMENTS

APT hospitals and staff providing data

Members of the APRS/APT QI Committee Dean V Coonrod, MD, MPH (Chair)

Linda A Meiner, MSN, RNC-NIC, NE-BC (Recording Secretary)

Rhonda Anderson, RN, DNSc, FAAN, FACHE

Alan D Bedrick, MD

Martin Celaya, MPH

Mary Ellen Cunningham, MPA, RN

C Kevin Huls, MD

Shelly Lanagan, MS, WHNP, RNC-OB, C-EFM

Hugh S Miller, MD

Carol Olson, MBA, BSN, RN

Enid Quintana-Torres, MPH

Sara Salek, MD and/or Eric Tack, MD

OBJECTIVES

Summarize available data that illuminates the health status of Arizona’s perinatal patients

Compare available annual data from APT certified facilities

Identify perinatal system opportunities for improvement

Identify outcomes of targeted perinatal certification efforts

DATA SOURCES

Unless noted on a particular slide – data taken from APT Annual Data submitted by our APT facilities

Committee has been asked to consider avoiding duplication of data from APT from birth certificates.

Thanks to all at facilities who do the important work of data collection.

Some new information was collected in 2017. No change for 2018.

SPEAKER DECLARATION

No conflicts of interest

ARIZONA BIRTH TRENDS

AZ POPULATION – FEMALES 15-44 YEARS

1,157,231

1,298,3051,312,687 1,320,640

1,050,000

1,100,000

1,150,000

1,200,000

1,250,000

1,300,000

1,350,000

2002 2014 2015 2016

Source: 2016 ADHS Population Health and Vital Statistics

2006-2017 AZ YEARLY BIRTHS

70000

75000

80000

85000

90000

95000

100000

105000

06 07 08 09 10 11 12 13 14 15 16 17

102042102687

99215

92616

87053

8519085725

8496386648

85024 84404

81664

Source: 2017 ADHS Vital Statistics

US BIRTH AND FERTILITY RATES

2018-2018 AZ MONTHLY BIRTHS

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Total Births Linear (Total Births)


TEEN BIRTHS IN ARIZONA (NOT PREGNANCIES)

188 170 161 105 67 46 40 50

4227 44504151

2910

24301770 1582

1420

7448

82967849

6401

5620 4807

4261

3916

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2004 2006 2008 2010 2012 2014 2015 2016

Under 15 Years 15-17 Years 18-19 Years


2012-2016 AZ MULTIPLE BIRTHS


81 102 68 84 73

2301

24452559

24342574

0

500

1000

1500

2000

2500

3000

2012 2013 2014 2015 2016

Triplets+ Twins

Note:

Past Years Peaks

Twins - 2693 in 2008

Triplets+ - 175 in 2008

AZ PAYEE FOR DELIVERIES

2000 2010 2013 2016

AHCCCS 42.5% 53.3% 53.9% 52.3%

IHS 1.7% 2.0% 1.3% 1.3%

Private

Insurance50.5% 41.0% 41.2% 40.9%

Self 3.2% 3.0% 3.5% 5.2%

Unknown 2.2% 0.7% 0.2% 0.3%


PRENATAL CARE IN ARIZONA – 1ST TRIMESTER

81.7% 82.6% 81.3%

66.0% 67.9%68.9%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

2011 2012 2013 2014 2015 2016

Change in Birth Certificate 2014

Source: 2016 ADHS Population Health and Vital StatisticsHP2020-MICH-10.1 Target is 77.9%

PRENATAL CARE IN ARIZONA – LATE OR NONE

3.1%3.2%

3.6%

5.3% 5.5% 5.6%

1.6%

1.2%1.4%

2.1% 2.2%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

2011 2012 2013 2014 2015 2016

3rd Trimester No PNC


% PRETERM AND LBW BIRTHS 2006-2016 10.6 10.3 10.2

9.6 9.3 9.2 9.0 9.0 9.0 9.0

7.1 7.1 7.1 7.1 7.0 6.9 6.9 7.0 7.2 7.3

1.2 1.2 1.2 1.1 1.2 1.2 1.1 1.2 1.1 1.2

0.0

2.0

4.0

6.0

8.0

10.0

12.0

2006 2007 2008 2010 2011 2012 2013 2014 2015 2016

Preterm <37wks LBW <2500g VLBW <1500g


HP2020-MICH-9.1 PTB Target – 11.4%

HP2020-MICH-8.1 LBW Target – 7.8%

HP2020-MICH-8.2 VLBW Target – 1.4%

2016 % AZ BIRTHS BY DAY OF THE WEEK

12%

16%

16%

16%

15%

14%

11%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Sat

Fri

Thur

Wed

Tues

Mon

Sun

Source: 2016 ADHS Population and Health Vital Statistics

2016 % AZ BIRTHS BY MONTH

8.4%

8.0%8.1%

7.8%

8.0% 8.0%

8.3%

9.1% 9.1%

8.5%

8.2%

8.6%

7.0%

7.5%

8.0%

8.5%

9.0%

9.5%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec


MARCH OF DIMES 2017 PREMATURE BIRTH REPORT CARD FOR ARIZONA

10.3%

9.7%

9.3%9.2% 9.1%

9.0%9.1% 9.1%

10.4%

10.0%

9.8% 9.8%9.6% 9.6% 9.6%

9.8%

8.0%

8.5%

9.0%

9.5%

10.0%

10.5%

11.0%

2007 2010 2011 2012 2013 2014 2015 2016

Arizona US

March of Dimes – PeriStats March of Dimes Goal 8.1% by 2020, 5.5% by 2030 HP 2020 Goal 11.4%


March of Dimes – PeriStats

8.6%

8.5%

9.2%

9.4%

12.2%

8.5%

8.9%

9.1%

10.5%

13.3%

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0%

Asian/Pacific Islander

White

Hispanic

American Indian/Alaskan Native

Black

2013-2015 Racial Disparity in Premature Live Births

US AZ


March of Dimes – PeriStats

9.0%

9.2%

8.5%

9.1%

8.3%

8.6%

7.8% 8.0% 8.2% 8.4% 8.6% 8.8% 9.0% 9.2% 9.4%

Pinal

Maricopa

Pima

Mohave

Yavapai

Yuma

2015 Preterm Birth Rates by County of Residence

% TOTAL CS, PRIMARY CS AND VBAC BIRTHS 2006-2016

26.0 26.6 27.5 27.7 27.6 27.9 27.6 27.8 27.6 27.627.4

17.2 17.1 17.4 17.614.9 14.7

16.9 16.7 16.4

15.8 15.6

5.4 5.5 6.7 6.4 5.9 6.7 7.68.6

15.2

16.2 17

0.0

5.0

10.0

15.0

20.0

25.0

30.0

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Total CS Primary CSec VBAC


HP2020-MICH-7.1 Prim Csec Target 23.9%

In low risk (FT, singleton, vertex)

AZ BIRTHS BY SETTING AND CHARACTERISTICS

AZ HOSPITAL BIRTHS BY LEVEL OF CARE - 2017IHBC

0.07% Level I5.55%

Level II23.95%

Level IIE26.05%

Level III41.06%

Non APT 3.29%

ED0.04%


96.7% of Arizona

Hospital Births

occur in APT

Certified Facilities

ALTERNATIVE BIRTH LOCATIONS AND TRENDS 2014-2017

2943

53

469

713

100

2787

15

505

725

468

2376

31

619713 712

0

500

1000

1500

2000

2500

3000

3500

Non APT Facilities Ermergency Depts FS Birthing Centers Home Births "Other Births"

2014 2015 2017Source: 2016 ADHS Vital Statistics

REGIONALIZATION – RIGHT LEVEL OF CAREVLBW, LBW AND HBW BIRTHS BY LEVEL - 2017

0 0 6 22 10

200

354

19 38

856

1668

38158

1308

1590

353

697

24232527

0

500

1000

1500

2000

2500

3000

ELBW <1000g VLBW <1500g LBW <2500g HBW 4000+

IHBC Level I Level II Level IIE Level III

BIRTH LOCATION - ELBW<1000G (ABOUT <28 WEEKS)

IHBC0%

I0%

II5%

IIE9%

III86%

2017IHBC0%

I2%

II5%

IIE7%

III86%

2016

BIRTH LOCATION - EGA<28 WEEKS

IHBC0%

I1%

II6%

IIE9%

III84%

2017IHBC0%

I3% II

4%

IIE7%

III86%

2016

BIRTH LOCATION - VLBW<1500G (ABOUT <30 WEEKS)

IHBC0%

I1%

II4%

IIE18%

III77%

2017IHBC0%

I2%

II5%

IIE16%

III77%

2016

HP2020-MICH-33

Target 83.7%

APT 93%

BIRTH LOCATION - LBW<2500G (ABOUT <36 WEEKS)

IHBC0%

I4%

II18%

IIE27%

III51%

2017 IHBC0%

I7%

II25%

IIE27%

III41%

2016

BIRTH LOCATION - EGA <36 WEEKS

IHBC0%

I2%

II13%

IIE26%

III59%

2017 IHBC0%

I3%

II13%

IIE24%

III60%

2016

Transports to and from APT Facilities 2017

IHBC I II IIE III Total

OB Sent 118 201 231 122 7 679

OB Rec’d 3 91 196 158 724 1172

Neo Sent 7 213 215 197 169 802

Neo Rec’d 0 0 1 4 61 66

Neo Back Sent0 2 18 172 324 516

Neo Back Rec’d0 0 30 25 24 79

INDUCTIONS 2011-2016

2012 2013 2014 2015 2016 2017

Number 21,810 21,653 19,899 19,517 17,419 18,562

Rate 27.2% 27.0% 24.8% 24.3% 21.7% 24.0%

21,810 21,65319,899 19,517

17,419

18,562

27.2% 27.0%24.8%

24.3%

21.7%24.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

0

5,000

10,000

15,000

20,000

25,000

INDUCTION RATES/TOTAL DELIVERIES BY LEVEL OF CARE

28.8%

23.6%

25.5%

23.2%

24.2%24.3%23.5%

25.0%

18.2%

21.7%

22.9%

26.5%

24.5%

22.6%

24.0%

15.0%

17.0%

19.0%

21.0%

23.0%

25.0%

27.0%

29.0%

31.0%

I II IIE III Total

2015 2016 2017

C-SECTION RATES AFTER INDUCTION

20.0%

16.0%

18.2%

17.1%17.3%

15.0%

16.0%

17.0%

18.0%

19.0%

20.0%

21.0%

I II IIE III Total

2017

PRIMARY CESAREANS 2012-2017

2012 2013 2014 2015 2016 2017

Number 12,016 12,328 11,785 11,371 11,112 10,667

Rate 15.2% 14.5% 14.2% 14.1% 13.8% 13.8%

12,016

12,328

11,785

11,371

11,112

10,667

15.2%

14.5%

14.2%

14.1%

13.8%

13.8%

13.0%

13.5%

14.0%

14.5%

15.0%

15.5%

9,500

10,000

10,500

11,000

11,500

12,000

12,500

PRIMARY C-SECTIONS RATES/TOTAL DELIVERIES BY LEVEL OF CARE

13.6% 13.4%14.3% 14.4%

14.1%

12.3% 13.0%13.7%

14.7%13.8%

11.6%

13.4%13.1%

14.9%

13.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

I II IIE III Total

2015 2016 2017

VBACS IN APT FACILITIES – 2014-2017

0 43

405342

1520

2310

0 43

446323

1130

1942

281

463

347

1041

1934

180

459 444

1083

2067

0

500

1000

1500

2000

2500


2014 2015 2016 2017

VBAC SUCCESS 2014-2017

82.5%

84.1%

81.2%80.7%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

2014 2015 2016 2017

RATE OF VLBW AND LBW DELIVERIESBASED ON DELIVERIES IN APT FACILITIES – 2014-2016

1.40%1.06% 1.19% 1.16%

7.80%

6.98%7.25%

6.16%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

HP 2020 Target 2015 2016 2017

VLBW <1500 LBW <2500HP2020 MICH 8.1 and 8.2

BIRTHS BY GESTATIONAL AGE

EGA Number Percent

<24 161 0.2%

24-27 299 0.4%

28-31 598 0.8%

32-35 3,247 4.2%

36-38 24,031 31.0%

39+ 49,101 63.4%

INSTRUMENT DELIVERIES – LEVEL OF CARE

0.0%

6.0%

3.9%3.6%

3.2%

3.6%

0.0%

5.1%

4.0%

3.5%

3.1%

3.6%

0.0%

6.0%

3.7% 3.7%

3.0%

3.5%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

IHBC Level I Level II Level IIE Level III All Levels

2015 2016 2017

GENERAL ANESTHESIA FOR C-SECTIONS– LEVEL OF CARE 2016 & 2017

5.4%

3.3% 3.3%3.5% 3.5%

5.4%

3.0%

3.6%3.3% 3.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Level I Level II Level IIE Level III All Levels

5 MIN APGARS 6 OR LESS – RATE BY LOC – 2016 & 2017

1.13%

0.9… 0.91%

1.57%

1.21%1.10%

1.25%

1.05%

1.45%

1.27%

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

1.40%

1.60%

1.80%

Level I Level II Level IIE Level III All Levels

ADMISSION TO CCN OR NICU – TOTALS BY LOC - 2017

2103

2882

4294

9279

36 220

443 669

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Level II Level IIE Level III All Levels

Inborn Transports

INBORN ADMISSION TO CCN OR NICU– RATE BY LOC 2017

11.5%

13.8%

13.1%

12.0%

10.0%

10.5%

11.0%

11.5%

12.0%

12.5%

13.0%

13.5%

14.0%

Level II Level IIE Level III All Levels

SCHEDULED DELIVERIES AT 36, 37 OR 38 WEEKS – NOT MED NECESSARY

2013

United States Average – 6% not medically necessary

Arizona Average – 7% not medically necessary

Involving at least 6061 newborns

APT Hospitals average 6.2% (Range 0 – 26%) – 38 hospitals reporting

Non APT Hospitals average 12.6% (Range 0 – 33%) – 5 hospitals reporting

2013 CMS Data – Analysis by Nathan Lepp, MD

SCHEDULED DELIVERIES AT 36, 37 OR 38 WEEKS – NOT MED NECESSARY

2015-16

APT Hospitals range from 0 – 25% - 37 hospitals reporting

2016-2017

APT Hospitals range from 0 – 9% - 39 hospitals reporting

2016-17 CMS Data – Based on a sample of cases

% 0 1 2 3 4 5 6 7 8 9 -- 25

2015-16 12 8 6 4 2 0 2 0 0 2 1

2016-17 18 2 3 2 5 0 1 2 2 2 0

EARLY ELECTIVE DELIVERIES APT DATA:APT 62 VS ABOUT 90 PER CMS

5

32

4

21

62

0.15

10.15

20.15

30.15

40.15

50.15

60.15

70.15

I II IIE III Total

2017

MATERNAL AND INFANT MORBIDITY AND MORTALITY

MAT DEATHS IN APT FACILITIES –DELIVERY ADMISSION 2015-2017

0 0

1

0

2

3

0 0 0 0

5 5

0 0 0 0

7 7

0

1

2

3

4

5

6

7

8


2015 2016 2017

PREGNANCY RELATED DEATHS: AZ VS 4 STATE REPORT

Hemorrhage24%

CV / HTN27%

Other49%

AZ N=37 Hemorrhage13%

CV / HTN32%

Other55%

4 State N=175

SEVERE MATERNAL MORBIDITY APT

012

47 49

99

207

0 9

49 43

98

196

021

96 92

197

403

0

50

100

150

200

250

300

350

400

450


Blood ICU Either

SEVERE MATERNAL MORBIDITY APTRATES PER 1000

2.352.57

2.34

3.01

2.68

2.001.76

2.68

2.05

2.98

2.54

3.50

4.00

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

I II IIE III Total Study 1 Study 2

Blood ICU

CDC ICD BASED SMM RATES

Source:https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

Accessed 7/27/18

“CDC” SMM ARIZONA 2016RATES PER 10,000 BY LEVEL

188.4

97.5

172.7

116.8 117.6

49.341.4

62.3

100.2

39.9

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

200.0

I II IIE III Non APT

SMM overall SMM no transfusion

“CDC” SMM ARIZONA 2016RATES PER 10,000

150.2

112.8

174.4 171.9

327.9

162.0

71.560.3

77.3 76.1

136.4

84.3

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

Overall NH White NH Black Hispanic NH Nat Am Asian/Pac Is

SMM overall SMM no transfusion

AIM STATE OVERALL SMM 4 COHORT RESULTSRATES PER 10,000

209.2 208.6

189.8 185.0

166.2

190.3

147.9

169.6

0.0

50.0

100.0

150.0

200.0

250.0

1 2 3 4

Pre Post

Decreases of:

20.5%

8.8%

22.1%

8.3%

Respectively

All statistically

significant

NEONATAL DEATHS IN APT FACILITIES– 2015-2017

0 417

25

155

201

1 312

19

162

197

0 621 15

148

189

0

50

100

150

200

250


2015 2016 2017

RATE OF CHILD DEATHS DUE TO PREMATURITYBORN BEFORE 37 WEEKS WITH NO UNDERLYING CAUSE OF DEATH OTHER TH AN PREMATURITY

3.0

2.7 2.6

2.3 2.3 2.2 2.42.6

2.1

1.9

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Rate per 1000 live births

2017 AZ Child Fatality Review Program

CHILD DEATHS DUE TO PREMATURITY - DISPARITYBORN BEFORE 37 WEEKS WITH NO UNDERLYING CAUSE OF DEATH OTHER TH AN PREMATURITY

52%

25%

17%

8%5%

40%45%

5% 6% 4%

0%

10%

20%

30%

40%

50%

60%

Hispanic White, non-Hispanic African American American Indian Asian

% Prematurity deaths % of Births

2017 AZ Child Fatality Review Program

NEONATAL MORTALITY BY BIRTHWEIGHTALL LEVELS COMBINED PER 1,000

Birthweight Number NMR

<500 100 610.00

500-999 312 179.49

1000-1499 491 32.59

VLBW 903 147.29

LBW 4,793 3.34

2500+ 71,997 0.26

4000+ 6,141 0.16

Neonatal deaths of

those < 500 gm

weeks made up

36% of the deaths

NEONATAL MORTALITY BY GESTATIONAL AGEALL LEVELS COMBINED PER 1,000

EGA Number NMR

<24 73 453.42

24-27 43 143.81

28-31 16 26.76

32-35 17 5.24

36-38 11 0.46

39+ 6 0.12

Neonatal deaths

of those < 24

weeks made up

44% of the

deaths

SUID, BY CAUSE (INFANTS <1YR)CHILD FATALITY REPORTS – 2011 - 2016

2011 2013 2015 2016

Sudden unexplained infant death 114 74 78 80

Death from unsafe sleeping

environment

64 65 74 79

Sleeping on side or stomach 36 28 25 24

Bed sharing with adult and/or

other children

36 34 36 41

2017 AZ Child Fatality Review Program - 24th Annual Report

• 93% determined to be preventable.

• African American and American Indian infant deaths disproportionately higher than population they

compose.

NAS IN APT FACILITIES

136

116152

533

838

0

100

200

300

400

500

600

700

800

900


2017

TRENDS IN NEWBORN HOSPITALIZATION DUE TO MATERNAL DRUG USE

Source: 2016 ADHS Population Health

and Vital Statistics

DISCUSSION – APRS/APT QI COMMITTEE GOALS

Follow IOM’s recommendation of “Measure, Report, Improve”

Investigate methods to leverage routinely collected data for tracking perinatal outcomes

Facilitate identification of improvement opportunities

Consider collaborative approaches to perinatal outcome improvementJoin AIM?

Work on NAS?

AND LET ME SAY……….

ARIZONA BIRTH DEMOGRAPHICS

Documents

SNAPSHOT OF APT QUALITY DATA 2015 - 2017 · SNAPSHOT OF APT QUALITY DATA 2015 - 2017 What’s happening in Arizona and in our APT facilities? Dean V Coonrod, MD-MPH Chair of the APRS/APT